REVIEW OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 18:10 265 © 2008 Elsevier Ltd. All rights reserved. Haematological management of obstetric haemorrhage Eleftheria Lefkou Beverley Hunt Abstract Obstetric haemorrhage (OH) remains the leading cause of maternal mor- bidity and mortality worldwide, 140 000–160 000 women die annually. Uterine atony (70%), and retained and invasive placentae remain the commonest causes. Rarely OH is due to an inherited bleeding disorder. Although risk factors and preventive strategies are documented, not all cases are expected or avoidable. Haematological management includes regular monitoring of full blood count and coagulation screen, with the appropriate use of blood products: red cells to maintain a Hb>8 g/dl; if APPT ratio and/or INR>1.5 then 15 ml/kg of fresh frozen plasma; if fbrino- gen<1 g/L, then cryoprecipitate with 10 bags, increasing fbrinogen by approximately 1 g; if platelets<50 × 10 9 then one single donor pool. As fbrinolytic activation occurs with blood loss, 1–2 g tranexamic acid is suggested as it is safe, but as yet no studies of its use in OH have been undertaken. The use of rFVIIa is also reviewed. Women with OH are at high risk of venous thromboembolism post delivery and thromboprophylaxis is recommended for these women once bleeding has ceased. Keywords blood components; obstetric haemorrhage; postpartum haemorrhage; recombinant factor VII (rFVIIa); tranexamic acid Introduction Obstetric haemorrhage (OH) remains the leading cause of mater- nal morbidity and mortality worldwide. It is estimated that one woman dies every 4 min of postpartum haemorrhage, that is 140 000–160 000 women die each year. OH is also responsible for 20 million cases of associated morbidity. Especially in the develop- ing world, the combination of maternal mortality from severe bleeding, hypertensive disease and infections is a staggering 500 deaths per 100 000 live births. It is recognized as ‘one of the major causes of maternal mortality in which women were dying needlessly for want of common skills that every midwife and practitioner should possess’. Although risk factors and preventive strategies are documented, not all cases are expected or avoidable. The management of OH depends on the cause and, in general, requires surgical and med- ical techniques and pharmaceutical and haematological support. According to The European Project on Haemorrhage Reduction Eleftheria Lefkou MD is a Clinical Fellow at Department of Haematology, Guy’s & St Thomas’ NHS Foundation Trust, London, UK. Beverley Hunt MB FRCP FRCPath MD is a Consultant at Department of Haematology, Guy’s & St Thomas’ NHS Foundation Trust, London, UK. (EUPHRATES) considerable variations were observed between the 14 participating European countries in the medical policies for the immediate management of postpartum haemorrhage; the use of pharmacological agents especially varied widely. Best practice in managing massive OH is not always followed. This seems in part to be due to poor understanding of the appro- priate use of blood components and pharmacological agents to reduce bleeding, perhaps due to poor education and lack of clinical trials. The aim of this article is to review the defnition, aetiology and evaluation of OH and to give practical guidelines for the haematological management. Definitions OH is defned by the World Health Organization (WHO) as a blood loss of more than 500 ml in the frst 24 h after birth, or of more than 1000 ml when caesarean section has been performed. But the quantity of blood loss is diffcult to calculate and there is a tendency to underestimate blood loss when it is less than 150 ml and to overestimate it when it is above 300 ml. A more comprehensive defnition could be, any blood loss which can provoke a physiological change threatening the wom- an’s life. This defnition includes women with severe anaemia in whom a blood loss of 200–250 ml can provoke serious events. According to the American College of Obstetrics and Gynecol- ogy (ACOG) OH is defned as either a 10% change in haemato- crit between admission and postpartum, or the need for a blood transfusion. Another categorization of OH is into early/primary (blood loss within the frst 24 h of delivery; this is the com- monest) and late/secondary (that which occurs from 24 h to 12 weeks postpartum). Primary OH can be either placental or non-placental. Special categories of OH are major and massive (severe) haemorrhage, which are cases in which the volume of blood lost is greater than 1000 ml (major) to 1500 ml (massive). Major OH can be defned as a drop in the haemoglobin levels≥4 g/dl and transfusions≥4 units of packed red cells. Massive haemorrhage is also defned as blood loss which requires the replacement of the patient’s total blood volume or transfusion of more than 10 units of red cells within 24 h. Other defnitions include blood loss requiring the replacement of 50% of total blood volume in 3 or less hours, or blood loss at the rate of more than 150 ml/min. Incidence OH occurs in up to 18% of births worldwide. In developed coun- tries the incidence of severe bleeding in childbirth has been esti- mated in various surveys to range between 4 and 5 per 1000 maternities, or 1 in 200–250 deliveries. In developed countries the fatality rate is between 1 in 600 and 1 in 800 cases of OH. In the UK the incidence of massive OH is quoted as 6.7 per 1000 deliveries. Globally OH remains one of the most important causes of maternal mortality, accounting for 11% of all maternal deaths. According to the latest Confdential Enquires into Maternal Deaths in the UK, 2003–2005 ‘Saving Mothers’ Lives’, almost three-ffths of women who died from OH received less than optimal care. There were also apparent failures in recognizing the signs and